5 years ago

NAT 6/08 - THL

NAT 6/08 - THL

Evaluation of a training

Evaluation of a training program to implement alcohol screening, brief intervention and referral to treatment in primary health care in Minas Gerais, Brazil tudes more inflexible and resistant to preventive health services. The findings suggest the need to better integrate preventive services between community health workers and the other health professionals. Other problems like the organization of services were also found to be important in the SBI implementation process, as suggested in the key informant interviews. Perhaps the most important effect of the training was the change in the professionals’ perceptions about risky alcohol use, which began to be seen as a general health problem, not only a mental health problem. Despite the positive changes in attitudes and knowledge observed following the training, subsequent inquiries at the various training sites revealed that no systematic implementation of routine alcohol screening was observed in these health centers. This is not to say that the knowledge, skills, and confidence gained from the training did not continue to be applied in routine clinical practice. But without the implementation of a routine screening program for all patients in these settings, the delivery of brief interventions is unlikely to reach large numbers of patients (Babor et al. 2006). Analysis of the key informant interview data helps to interpret these findings, and to explain the general failure to implement the SBI program in routine clinical practice. From the beginning, they reported high expectations for the alcohol SBI training program because of the importance of the topic in the local health system and the need for adequate professional training. After the training, however, many difficulties were experienced, such as lack of 536 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 time, excess work duties, lack of motivation, resistance to working with alcohol issues, inadequate system infrastructure, incomplete teams, lack of official support by the government and difficulties in referring patients. In spite of the difficulties pointed out by these professionals, almost all of the study’s participants recognized the importance of the training and the SBI strategies employed. Many of the professionals reported implementing at least some of the recommended measures, within the resource limits of each center. For this reason, a more comprehensive and contextualized analysis needs to be done to determine the optimal circumstances that facilitate implementation of alcohol screening and brief intervention. It is clear, however, from the correlational analyses of predictors of screening and brief intervention that self-efficacy and positive expectancies are important to successful implementation, and perceived obstacles are a significant impediment. In spite of the general failure of the longterm implementation of SBI programs at these sites, some positive changes were observed in the adaptation of SBI to daily practice. An important thing to remember is that health policy changes are influenced by ideological, economic, epidemiological, social and many others factors. The evaluation process of projects like the one described here is very complex and must be conducted over a relatively long observation period to understand implementation. Twenty years ago a major change process started in the Brazilian health system, with the implementation of a primary health care model through-

out the country. Changes are still occurring, showing that the introduction of new health promotion services is a gradual process. This can serve as an example to explain the project’s difficulties as well as successes. More than that, it is the challenge of changing the way that health care is conceptualized and delivered in Brazil, focusing on health promotion and prevention as well as curative medicine, that may best explain the findings reported in this study. REFERENCES Anderson, P. & Kaner, E. & Wutzke, S. & Wensing, M. & Grol, R. & Heather, N. (2003): Attitudes and Management of Alcohol Problems in General Practice: Descriptive Analysis Based on Findings of a World Health Organization International Collaborative Survey. Alcohol & Alcoholism 38 (6): 597–601 Babor, T.F. & Higgins-Biddle, J.B. & Dauser, D. & Burleson, J.A. & Zarkin, G.A. & Bray, J. (2006): Brief interventions for at-risk drinking: patient outcomes and cost-effectiveness in managed care organizations. Alcohol & Alcoholism 41 (6): 624–631 Babor, T.F. & Higgins-Biddle, J. (2001): Brief Intervention for Hazardous and Harmful Drinking. A Manual for Primary Care, 2nd edition. World Health Organization: Geneva, Switzerland Babor, T.F. & Higgins-Biddle, J. & Dauser, D. & Higgins, P. & Burleson, J. (2005): Alcohol screening and brief intervention in primary care settings: Implementation models and predictors. Journal of Studies on Alcohol 66 (3): 361–369 Evaluation of a training program to implement alcohol screening, brief intervention and referral to treatment in primary health care in Minas Gerais, Brazil Telmo M. Ronzani, Prof. dr. department of Psychology Federal university of juiz de Fora juiz de Fora, Brazil e-mail: Michaela Bitarello do Amaral department of Psychobiology Federal university of são Paulo, sao Paulo, Brazil e-mail: Maria L. O. de Souza Formigoni department of Psychobiology Federal university of são Paulo, sao Paulo, Brazil e-mail: Thomas F. Babor, Ph.d., M.P.h. department of community Medicine university of connecticut health center, Farmington, connecticut, usa e-mail: Babor, T.F. & Higgins-Biddle, J. & Higgins, P. & Gassman, R. & Gould, B. (2004): Training medical providers to conduct alcohol screening and brief intervention. Substance Abuse 25(1): 17–26 Bardin, L. (2006): Content Analyses (Análise de conteúdo). Edições 70, Lisboa Church, O.M. & Babor, T.F. (1995): Barriers and breakthroughs: Substance abuse curricula in nursing education. Journal of Nursing Education 34 (6): 278–281 Collins, T. (2005): Health Policy analysis: a simple tool for policy makers. Public Health 119: 192–196 Denzin, N.K. & Lincoln, Y. (eds.)(2005): The SAGE Handbook of Qualitative Research. 3rd ed. Sage Publications, London Gomel, M.K. & Wutzke, S.E. & Hardcastle, D.M. & Lapsley, H. & Reznik, R.B. (1998): Cost-effectiveness of strategies to market and train primary health care physicians in brief intervention techniques for hazardous alcohol use. Social Science and Medicine 47 (2): 203–211 Heather, N. (2007): A Long-standing World NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 537

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